MORELLE

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Via S5845 - Signed by Governor

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A8512 - Summary

S T A T E O F N E W Y O R K
________________________________________________________________________
8512
2011-2012 Regular Sessions
I N A S S E M B L Y
June 22, 2011
___________
Introduced by M. of A. MORELLE -- read once and referred to the Commit-
tee on Insurance
AN ACT to amend the insurance law, in relation to coverage for the
screening, diagnosis and treatment of autism spectrum disorder; and to
amend a chapter of the laws of 2011 amending the insurance law relat-
ing to coverage for the screening, diagnosis and treatment of autism
spectrum disorder, as proposed in legislative bill numbers S. 4005-A
and A. 6305-A, in relation to the effectiveness of such chapter
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subparagraphs (B) and (C) of paragraph 25 of subsection (i)
of section 3216 of the insurance law, as added by a chapter of the laws
of 2011 amending the insurance law relating to coverage for the screen-
ing, diagnosis and treatment of autism spectrum disorder, as proposed in
legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as
follows:
(B) Every policy which provides physician services, medical, major
medical or similar comprehensive-type coverage shall provide coverage
for the screening, diagnosis and treatment of autism spectrum disorder
in accordance with this paragraph and shall not exclude coverage for the
screening, diagnosis or treatment of medical conditions otherwise
covered by the policy because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the super-
intendent and shall be consistent with those imposed on other benefits
under the policy. COVERAGE FOR APPLIED BEHAVIOR ANALYSIS SHALL BE
SUBJECT TO A MAXIMUM BENEFIT OF FORTY-FIVE THOUSAND DOLLARS PER YEAR PER
COVERED INDIVIDUAL AND SUCH MAXIMUM ANNUAL BENEFIT WILL INCREASE BY THE
AMOUNT CALCULATED FROM THE AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF
THE MEDICAL COMPONENT OF THE CONSUMER PRICE INDEX. This paragraph shall
not be construed as limiting the benefits that are otherwise available
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD12076-04-1

A. 8512 2
to an individual under the policy, provided however that such policy
shall not contain any limitations on visits that are solely applied to
the treatment of autism spectrum disorder. No insurer shall terminate
coverage or refuse to deliver, execute, issue, amend, adjust, or renew
coverage to an individual solely because the individual is diagnosed
with autism spectrum disorder or has received treatment for autism spec-
trum disorder. Coverage shall be subject to utilization review and
external appeals of health care services pursuant to article forty-nine
of this chapter as well as, case management, and other managed care
provisions.
(C) For purposes of this paragraph:
(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
(ii) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and behav-
ior.
(iii) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided or supervised by a behavior analyst certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant
to this paragraph shall be subject to standards of professionalism,
SUPERVISION and relevant experience pursuant to regulations promulgated
by the superintendent in consultation with the [commissioner] COMMIS-
SIONERS of health AND EDUCATION.
(iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations, or tests to diagnose whether an individual has autism spectrum
disorder.
(v) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
(vii) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the psychol-
ogist practices.
(viii) "therapeutic care" means services provided by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(ix) "treatment of autism spectrum disorder" shall include the follow-
ing care and [related equipment] ASSISTIVE COMMUNICATION DEVICES
prescribed or ordered for an individual diagnosed with autism spectrum
disorder by a licensed physician or a licensed psychologist:
(1) behavioral health treatment;
(2) psychiatric care;
(3) psychological care;
(4) medical care provided by a licensed health care provider;
A. 8512 3
(5) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
(6) pharmacy care in the event that the policy provides coverage for
prescription drugs.
S 2. Subparagraphs (B) and (C) of paragraph 17 of subsection (l) of
section 3221 of the insurance law, as added by a chapter of the laws of
2011 amending the insurance law relating to coverage for the screening,
diagnosis and treatment of autism spectrum disorder, as proposed in
legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as
follows:
(B) Every group or blanket policy which provides physician services,
medical, major medical or similar comprehensive-type coverage shall
provide coverage for the screening, diagnosis and treatment of autism
spectrum disorder in accordance with this paragraph and shall not
exclude coverage for the screening, diagnosis or treatment of medical
conditions otherwise covered by the policy because the individual is
diagnosed with autism spectrum disorder. Such coverage may be subject to
annual deductibles, copayments and coinsurance as may be deemed appro-
priate by the superintendent and shall be consistent with those imposed
on other benefits under the group or blanket policy. COVERAGE FOR
APPLIED BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF
FORTY-FIVE THOUSAND DOLLARS PER YEAR PER COVERED INDIVIDUAL AND SUCH
MAXIMUM ANNUAL BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE
AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE MEDICAL COMPONENT OF
THE CONSUMER PRICE INDEX. This paragraph shall not be construed as
limiting the benefits that are otherwise available to an individual
under the group or blanket policy, provided however that such policy
shall not contain any limitations on visits that are solely applied to
the treatment of autism spectrum disorder. No insurer shall terminate
coverage or refuse to deliver, execute, issue, amend, adjust, or renew
coverage to an individual solely because the individual is diagnosed
with autism spectrum disorder or has received treatment for autism spec-
trum disorder. Coverage shall be subject to utilization review and
external appeals of health care services pursuant to article forty-nine
of this chapter as well as, case management, and other managed care
provisions.
(C) For purposes of this paragraph:
(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
(ii) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and behav-
ior.
(iii) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided or supervised by a behavior analyst certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant
A. 8512 4
to this paragraph shall be subject to standards of professionalism,
SUPERVISION and relevant experience pursuant to regulations promulgated
by the superintendent in consultation with the [commissioner] COMMIS-
SIONERS of health AND EDUCATION.
(iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations, or tests to diagnose whether an individual has autism spectrum
disorder.
(v) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
(vii) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the psychol-
ogist practices.
(viii) "therapeutic care" means services provided by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(ix) "treatment of autism spectrum disorder" shall include the follow-
ing care and [related equipment] ASSISTIVE COMMUNICATION DEVICES
prescribed or ordered for an individual diagnosed with autism spectrum
disorder by a licensed physician or a licensed psychologist:
(1) behavioral health treatment;
(2) psychiatric care;
(3) psychological care;
(4) medical care provided by a licensed health care provider;
(5) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
(6) pharmacy care in the event that the policy provides coverage for
prescription drugs.
S 3. Subsection (ee) of section 4303 of the insurance law, as added by
a chapter of the laws of 2011 amending the insurance law relating to
coverage for the screening, diagnosis and treatment of autism spectrum
disorder, as proposed in legislative bill numbers S. 4005-A and A.
6305-A, is amended to read as follows:
(ee) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation which provides coverage for
hospital or surgical care coverage shall not exclude coverage for
screening, diagnosis and treatment of medical conditions otherwise
covered by the [policy] CONTRACT solely because the treatment is
provided to diagnose or treat autism spectrum disorder.
(2) Every [policy] CONTRACT which provides physician services,
medical, major medical or similar comprehensive-type coverage shall
provide coverage for the screening, diagnosis and treatment of autism
spectrum disorder in accordance with this subsection and shall not
exclude coverage for the screening, diagnosis or treatment of medical
conditions otherwise covered by the [policy] CONTRACT because the indi-
vidual is diagnosed with autism spectrum disorder. Such coverage may be
subject to annual deductibles, copayments and coinsurance as may be
deemed appropriate by the superintendent and shall be consistent with
those imposed on other benefits under the [policy] CONTRACT. COVERAGE
FOR APPLIED BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF
FORTY-FIVE THOUSAND DOLLARS PER YEAR PER COVERED INDIVIDUAL AND SUCH
MAXIMUM ANNUAL BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE
A. 8512 5
AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE MEDICAL COMPONENT OF
THE CONSUMER PRICE INDEX. This paragraph shall not be construed as
limiting the benefits that are otherwise available to an individual
under the [policy] CONTRACT, provided however that such [policy]
CONTRACT shall not contain any limitations on visits that are solely
applied to the treatment of autism spectrum disorder. No insurer shall
terminate coverage or refuse to deliver, execute, issue, amend, adjust,
or renew coverage to an individual solely because the individual is
diagnosed with autism spectrum disorder or has received treatment for
autism spectrum disorder. Coverage shall be subject to utilization
review and external appeals of health care services pursuant to article
forty-nine of this chapter as well as, case management, and other
managed care provisions.
(3) For purposes of this subsection:
(A) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
(B) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and behav-
ior.
(C) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided or supervised by a behavior analyst certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant
to this subsection shall be subject to standards of professionalism,
SUPERVISION and relevant experience pursuant to regulations promulgated
by the superintendent in consultation with the [commissioner] COMMIS-
SIONERS of health AND EDUCATION.
(D) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations, or tests to diagnose whether an individual has autism spectrum
disorder.
(E) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(F) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
(G) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the psychol-
ogist practices.
(H) "therapeutic care" means services provided by licensed or certi-
fied speech therapists, occupational therapists, social workers, or
physical therapists.
(I) "treatment of autism spectrum disorder" shall include the follow-
ing care and [related equipment] ASSISTIVE COMMUNICATION DEVICES
prescribed or ordered for an individual diagnosed with autism spectrum
disorder by a licensed physician or a licensed psychologist:
(i) behavioral health treatment;
A. 8512 6
(ii) psychiatric care;
(iii) psychological care;
(iv) medical care provided by a licensed health care provider;
(v) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
(vi) pharmacy care in the event that the [policy] CONTRACT provides
coverage for prescription drugs.
(4) Coverage may be denied on the basis that such treatment is being
provided to the covered person pursuant to an individualized education
plan under article eighty-nine of the education law. The provision of
services pursuant to an individualized family service plan under section
twenty-five hundred forty-five of the public health law, an individual-
ized education plan under article eighty-nine of the education law, or
an individualized service plan pursuant to regulations of the office for
persons with developmental disabilities shall not affect coverage under
the policy for services provided on a supplemental basis outside of an
educational setting if such services are prescribed by a licensed physi-
cian or licensed psychologist.
(5) Nothing in this subsection shall be construed to affect any obli-
gation to provide services to an individual under an individualized
family service plan under section twenty-five hundred forty-five of the
public health law, an individualized education plan under article eight-
y-nine of the education law, or an individualized service plan pursuant
to regulations of the office for persons with developmental disabili-
ties.
(6) Nothing in this subsection shall be construed to affect any obli-
gation to provide coverage for otherwise-covered services solely on the
basis that the services constitute early intervention program services
pursuant to section three thousand two hundred thirty-five-a of this
article or an individualized service plan pursuant to regulations of the
office for persons with developmental disabilities.
(7) Nothing in this subsection shall be construed to prevent a [poli-
cy] CONTRACT from providing services through a network of participating
providers who shall meet certain requirements for participation, includ-
ing provider credentialing.
S 4. Section 5 of a chapter of the laws of 2011 amending the insurance
law relating to coverage for the screening, diagnosis and treatment of
autism spectrum disorder, as proposed in legislative bill numbers S.
4005-A and A. 6305-A, is amended to read as follows:
S 5. This act shall take effect [on the first of January next succeed-
ing the date on which] ONE YEAR AFTER it shall have become a law and
shall apply to all policies and contracts issued, renewed, modified,
altered or amended on or after such date.
S 5. This act shall take effect immediately; provided, however, that
sections one, two and three of this act shall take effect on the same
date and in the same manner as a chapter of the laws of 2011 amending
the insurance law relating to coverage for the screening, diagnosis and
treatment of autism spectrum disorder, as proposed in legislative bill
numbers S. 4005-A and A. 6305-A, takes effect.

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